Texas Supportive Decision Making Act and the ICF/IID Programs

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Provider letter 16-13 (  Information Letter No. 16-13 — Supported Decision-MakingAgreement Act ) introduced the Supported Decision Maker to just about every program in the state of Texas as an alternative to guardianship.  Unfortunately, for the ICF/IID programs, it ultimately presents more concerns than it does supports and may really be a problem for ICF/IID use.

The act presents a “Supported Decision Maker” into the equation for ICF/IID, or a SDM.  It should not be confused with a “Surrogate Decision Maker” from the Surrogate Program that is also known as an “SDM”.  This act is entirely separate from the surrogate program.  It does present some potential concerns when dealing with the surrogate program for individuals who have always depended on that program.

A quick read through the role of an SDM will indicate that the SDM is to gather information and to communicate the individual’s “life decisions”.  This is all done after the individual (the client in the ICF/IID) signs a supported decision-making agreement with the person who will serve as the SDM.   The SDM does not make the decisions, but only helps the person make the decisions and then communicates the person’s decision to the appropriate person(s).  It sounds all straight forward in a basic reading.

After reading over the entire act, the sample agreement, and the responsibilities of the SDM, there are several concerns that may need to be addressed by the next legislative session:

1.  This act does nothing to resolve the “waiting” period faced by ICF/IID providers when it comes to the Surrogate Decision Making Program.  The program often can take months to complete and obtain a legal consent for things needed immediately such as psychotropic medications.  The facility and IDTeam usually has no choice except to give the medications while consent through the Surrogate Program is being sought.  A better use for the SDM would have been to have this person make a decision pending a Surrogate Decision Making Committee’s review of the decision, but that application would only apply to ICF/IID programs that use the Surrogate Program.

2.  This act allows 14 year olds to sign the agreement as a witness.  Since a 14 year old is not a legal adult, there can and will likely be problems with those signatures being considered “legal” witnesses to the agreement.

3.  The act assumes the person with the disability requires assistance with making decisions without any assessment to determine if that individual needs assistance.  Further, if the individual needs assistance in making decisions, then who decides the individual with disabilities has the ability to understand and sign the agreement to obtain an SDM?

4.  Some providers may see this as an avenue to avoid the Surrogate Decision Making Program’s long, and often paperwork intensive, procedures.  If a facility does decide to use the SDM and avoids the Surrogate program, what grounds will a surveyor have to cite the facility regarding consents?  Will the surveyor refer to prior Surrogate use?  The new law creates some confusion here since the SDM presents information and communicates the person’s decision.  If the decision is “I want to take Risperdal,” and that is communicated, then in theory the IDTeam could accept this as consent without using the Surrogate Program.  Again, this is going to create issues for the surveyor and the provider as to how to defend their cases for or against deficient practice.

5.  The act also gives no consideration to the level of disability.  It simply “assumes” that a few questions can be presented to anyone with disabilities and he or she will decide they “want” an SDM.  Based on the wording, a person with Profound Intellectual Disabilities who simply nods his or her head at the right time during questions, could sign the agreement.  The SDM could then present that individual’s “decision” to the rest of the IDTeam based on whatever efficient level of communication the SDM has with the individual.   There would be no way of telling if the person really wanted the SDM or really made the decision as presented.   

6.  The act does not give any consideration to other assessments.  For example, if a person has been using the Surrogate Program for consent for psychotropic medications – does the assessment from the previous Surrogate Application mean the person can not obtain a Supportive Decision Maker?  If the person does obtain a SDM, what grounds does that leave for surveyors who believe the person can not give consent?

7.  Since anyone can be an SDM in this program, it means that Administrators, QIDPs, Managers and even direct care staff could sign the agreement.  For that matter, a person’s physician could sign the agreement, present the information to the person, and then communicate that person’s decision to the facility regarding surgery, medications, etc.  This would then mean that consent is assumed by the person’s decision.

Overall, the Supportive Decision Making Act can likely be a benefit to many programs in the state.  It has been applied to the ICF/IID programs, but probably should not have been.  It will create confusion and in some cases such as situation when a surveyor writes deficient practice pertaining to consents, the SDM may be the fall back defense in an Informal Dispute Resolution (IDR) or even a lawsuit presented by the provider or the SDM.  In theory, the provider could present that the SDM provided the individual’s decision regarding an issue and that the decision was then accepted as consent.    In such a case as this, should it reach a legal level, it would be up to a court to determine if the person had ever been “deemed incompetent in a court of law,” and usually if they have not, then the court considers that person competent to make his or her own decisions. 

The Most Overlooked Disaster Item in the ICF/IID

The state and federal standards are the minimum requirements needed to operate an ICF/IID program and those standards are often low in all areas including disaster plans.  In Texas, a disaster plan has a good deal of items and information required.  You must have food, clothing, medications, etc. as a norm.  There is one important issue that the state requirements overlook when it comes to disasters.

Consider the potential for a disaster at your facility.  You have made preparations.  You have all your required supplies, you have a disaster plan, and you have staff willing to work during the disaster.  The day comes and disaster strikes.  You are not required to evacuate, but your facility is without power, without water, and without phone service.  You expect it is going to be three to four days before these items are restored.  Your staff use flashlights at night, all the medications you need are on-site, you have water, you have food, and things are going along just fine.  You can not see any potential problems, until someone has to go to the restroom.  Because your facility is in the middle of town, it's not like you can go out into the woods.  No, you are stuck with two options.  You could use your three day supply of toilet paper, because you know you have those standards supplies on hand as all ICF/IID programs should.  Once you use your bathroom though you are faced with a major problem.  You could use some of your drinking water to flush the toilet, and hope that the sewer lines are not part of the services that have been cut, or you could have everyone use the toilet and simply leave it until the utilities are back.  The problem with leaving it is that it becomes smelly, it promotes a potential health hazard, and depending on how long the crisis last, it could be a major issue to flush the toilet once utilities do come back.   That's your first option in a nutshell, or you could be prepared.

The second option that you could have in place is to purchase five gallon buckets - the kind you find at hardware stores - and go to a sporting goods store and purchase a toilet seat made for the five gallon buckets - yes, they make a special seat to attach.  Now the people you serve can use the toilet with dignity and still within the bathroom.  Once finished, the bucket can be emptied into a trash bag or cleaned through another approved method.  Between bathroom usage, the bucket can be put outside.  This will help avoid the smell, the health hazard, and the potential for a really bad clogged toilet once the power and utilities do come back.  You may want to consider a few of these buckets so that rotations can be maintained.

The bottom line is the state's directives for a disaster plan and supplies is good, but it does not cover everything.  Consider bathroom needs and the preparation that can go into getting ready for a disaster to ensure you face no problems.

I am not trying to promote anyone's website, but here is a link to a potential toilet bucket - just remember, you can get your own going easily through places like Lowes and Home Depot, and there are several other organizations selling complete kits as well: Bucket Toilet Example 

"Real" Money for Training in the ICF/IID Program

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If you are in Texas, if you go through annual surveys, and if you have individuals living in the ICF training on money management skills (you better have) then you may have faced the "Fake Money" issue.  There are several ICF programs in Texas that have received deficient practice for failing to use "Real" money in their training programs.  Often these programs note several reasons for not using real money such as "The clients will take it," "The staff will take it," or "Real money simply disappears."  By most people's standards, those are all good reasons to make fake money.  The fact is a small purchase of "Fake" money can cover bills and coins ranging from pennies up to hundred dollar bills for training.  If they are lost, torn up, or even thrown away there is usually plenty more in the set to be used (see picture above).  The argument sounds solid until the surveyor walks through the door.

If you have gone through a survey and had "Fake" money, then there is a good chance that it was an area of concern at the least, and possibly written into deficient practice at the most.  Several sets of deficient practice I have seen have listed it as an example under Active Treatment or the famous "W159" or as some call it "The QIDP Tag".  There has always been the possibility of filing an Informal Dispute Resolution (IDR) in Texas over the issue, but the fact is the example of the "Fake" money is usually worked into a tag with several other issues.  In the end you might get the example removed, but in most cases you would still have the tag to contend with for your plan of correction (POC).

After a home recently received the "Fake" money as an example under a tag, I decided to read the specific tag that was written.  This, as warned above, was a situation where several examples were listed to support the tag and planning an IDR simply was not as feasible as correcting the tag.  ONce you start looking at the Federal Standards, you can find the word "Money" mentioned 19 times.  Since "Fake" and "Real" "money" was the issue, there was no reason to search anything else.  Out of the 19 times money is mentioned, the tie to training only falls under tag W126.

W126 deals with encouraging and allowing the individuals (clients) to manage their financial affairs and for the facility to teach them how to manage their money if they do not know how to do it.  It is not until you read into the guidelines that you find the mention of money brought up.  Remember, these guidelines are the guide for surveyors to use when they are in the facility.  In the third full paragraph we find the following statement:

"Money management includes a broad spectrum of programs with varying levels of participation by the client ranging from the use of choice in money expenditures, to an understanding of the concept of money, and ultimately to actual money handling and budgeting. The IDT must not conclude that a money management program is inappropriate based solely upon the level of intellectual or physical disability of the client."

The first thing the reader will notice is that money management "includes a broad spectrum of programs and varying levels of participation".  This statement supports the IDTeam's efforts for some people to manage checkbooks, others to take care of banking needs, and still others to study the meaning and use of something as small as a penny.  In other words, through assessments the IDTeam has to determine at what level and what training the individual needs for money management.   The next interesting thing to note is that the guide states "...ultimately to actual money handling".  This statement would seem to support a facilities use of "Fake" money and even the use of pictures, or references of some kind to something other than actual money.  So, with this in mind, how can the facility use fake money in a world where the surveyors seem to insist on "Real" money for training only?

You basically have two choices.  You could simply use real money and avoid all confrontation.  That would be the simple method.  The second method you could use is documentation.  Documentation would need to be very strong for your case.  For example, what are the reasons you can not use "Real" money?  Maybe it's a case where the person you are training eats the money, throws it away, tears it up during training, etc.  Is there a plan to work toward "Real" money eventually?  You would clearly need to demonstrate the pattern.  For example, a person might use "Fake" money because he tears it up, but part of his training is to not tear the money up.  So, at some point, "Real" money could be used - remember the guidelines state your goal is "ultimately to actual money handling."

There are multiple ways that an IDT could address the issue and justify the use of "Fake" money for training.  However, the bottom line is that you must have solid documentation, justification, and a goal in place to work toward the eventual use of "Real" money.  If you put these in place, it is doubtful that most surveyors would write an example of "Fake" money into deficient practice- and while doubtful that they would write the "Fake" money into deficient practice, it is almost a certainty that they would not write it under W126.   Remember, the surveyor writes the 2567 in such a way that it can stand alone as evidence.  This is done to protect the survey process, the individual's we serve, and to ensure that should the 2567 be called into question through an IDR or another avenue of review, it can stand as evidence alone of the deficient practice.

One final thought before you go out and buy up ton's of "Fake" money to use.  Do your documentation as discussed above, and consider contacting your program manager for the region you operate in (if in Texas).  Talk with the Program Manager about your reason for wanting to use "Fake" money.  If you do that, then odds are the Program Manager will talk with surveyors before they come to your facility.  You may be able to avoid having "Fake" money as an example in the 2567, and you will not have to waste time and resources with an IDR for what will likely be an example in a tag only.

Reference:
State Operations Manual. Washington: U.S. Dept. of Health, Education, and Welfare, Social Security Administration, 2015. CMS. CMS, 14 Aug. 2015. Web. 2 Apr. 2016. W126 page 48-49

The IDTeam Approach

Too often QIDP/QDDP's feel the urge to cure or come up with all the answers.  It is not entirely the QIDP's fault.  It often goes back to the organization that places everything on the shoulder's of the QIDP.  The general feeling becomes "Send it to the Q, he or she will know what to do."  While all QIDP's wish they had all the answers, the fact is nobody has all the answers.  This was recognized years ago when the federal standards for ICF/IID programs were first developed.  That is why the standards set forward the need for an IDTeam approach.

For the few reading this who may not know, IDTeam stands for Interdisciplinary Team.  Just like the word says, it means a team approach from a group of different disciplines.  Input can be taken from the QIDP, shift managers, direct care staff, nurses, administrators, physicians, dentist, and other specialist.  All this input comes together to form the IDTeam.  Generally meetings are held with the client (person served), their guardian or involved family member, the QIDP, a manager, a direct care, and a nurse at minimum.  Everyone brings input from different areas to help solve a problem.  For example, the nurse may present the physician's recommendations for a new medication, a direct care staff may point out some informal training that has worked with the client, the involved family member may know routines that helped at home, and the client may be able to tell everyone how he or she feels about something.

When the IDTeam comes together it is not the responsibility of the QIDP to have or present all the ideas.  It is the QIDP's responsibility to coordinate the ideas and implement the ones the IDTeam agrees to.

I watched this concept recently demonstrated in an ICF/IID program where the Floor Supervisor, Sarah Ostlund, presented a unique idea to help a client stop slamming the door to his bedroom into the wall.  While everyone was considering medications, one-on-one staff, and even expensive door control devices, Sarah obtained a simple pool noodle, cut it in three pieces and attached them by screws to the back of the door.  After some experimentation, she found that the client would still slam the door, but now the effect was softened by the pool noodle.  Sarah presented the idea and her results to an IDTeam that was seeking more expensive means to address the problem.

Once presented, the IDTeam adopted the swimming noodles attached to the client's door as part of the IPP.  Eventually, without the results of damaged walls and the loud noise, the facility saw a decrease in the door being slammed open by this client.

In all honesty, had the IDTeam depended solely on the QIDP to come up with an idea, it is very likely that a new behavior plan, an increase of one-on-one staff, and maybe even medication modifications would have been tried first.  Sarah ended up saving the facility and the client from a lot of undue expenses and hardships.  The swim noodle, that I now call a "Door Noodle" continues to work at this time.

Sarah Ostlund is the Floor Supervisor and Placement Coordinator for Caring Palms ICF/IID program in Brownsville, Texas.  Caring Palms   Sarah's "Door Noodles" below:

Wanted!

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In life most people have a basic need to be "wanted," desired, sought after, or loved.  It's something that drives us to build friendships, it drives up to grow loving relationships and it pushes us to family reunions year-after-year so we can have our parents and grandparents tell us how much they miss us.  We want to be wanted.  In the field of developmental disabilities there are often few rewards.  The money is not great, the benefits are few, and the hours are long, but the opportunity to be wanted and loved is always present.

I was recently working in an office as some people with disabilities left their workshop in the room next to me.  I heard one individual talking with a staff and her question was simple.  She asked, "When are you going to work in my house again?"  The staff responded that she did not know and then asked, "Do you want me to come work at your home?"  The response was immediate, "Yes."
It was a simple interaction that I intruded on by listening to the conversation.  I happened to be at an angle where I could turn in my seat and watch the staff.  What I saw was amazing.  The staff was smiling, she hugged the person, and told her that she would see what she could do about working at the young lady's home again soon.  The staff was "wanted."

Too often we forget that the unconditional love, admiration, and even friendship that we so often seek from family members and friends outside work, can be found in the hearts and minds of the people we serve.  Jesus once said that we must approach the Kingdom of Heaven and accept it with the mind of a child.  The people we serve are often noted to have IQ levels around the age of four to five year old children.  Even though they come to us in the body of a thirty-five year old, or forty year old etc, they come with the mind of a child.  They come with an unconditional love that mimics that childlike approach Jesus discussed about the Kingdom of Heaven.  They accept us with our faults, our short-comings, and often without knowing anything about our lives outside of work.  That unconditional love pushes them to a love that is "wanting".  They "want" us in their lives.  They "want" us working with them, visiting them, and spending time with them.

You will receive a lot of gifts in your lifetime.  Friends will give you birthday presents, loved ones will give you Christmas presents, and others will give you all sorts of gifts over your lifetime.  The gift of being "wanted" though is one that is expected from your family and even your friends, but it is one that is often given freely and in love from the people we serve without any strings or any expectations.  They innocently reach out to us and they honestly want us involved in their lives, and there can be no greater gift than to be wanted unconditionally.

New Year QIDP / QDDP Task

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Well 2016, arrived and if you are like most people it got here way too fast.  You still have your books all set for 2015, all your plans are based in 2015 and for the next three months you will be scratching out your "5" to make it a "6" on everything you sign.  The good news though is there are some things as a QIDP that you can do now to ease the transition into the new year.  Some of these suggestions will apply to all QIDP/QDDP, and some will only apply to Texas QIDPs, but at least you will have a list to start out on the right foot for 2016.

The first thing you should do for 2016, is consider your annual dates.  You might as well make a calendar for the following at a minimum:

1.  Annual staffing dates
2.  Fire Drill schedule
3.  School start and stop dates (if you work with any people in school)
4.  EMR check schedules -required annually in Texas
5.  CPR renewal dates
6.  Annual medical appointment dates - hopefully your nurse will complete this part

Most of the above can easily be placed on a Google or Apple calendar.  You can then set the calendar to remind you of the event a few days or weeks in advance.

Since January 2016 is usually the start of the cold season - at least it usually is in Texas - you need to consider your annual inspections.  You need to have the heat unit inspected - especially gas units (a pre-season check).  You need to look at your fire extinguishers and see what month you should schedule their updates while reminding yourself to check the unit monthly.  You need to look at your alarm inspections -fire, and other alarms- and see when they are due.  Finally, if you use flame resistant treatment for curtains, you may need to check those dates and see if this is the year for updated treatment.

This time of the year may also be a good time to have maintenance, check your appliances, furniture, etc.  It could also be a good time for clothing inventory and updates.  There's a good chance that several people may have new clothing from Christmas so now is a good time to clean up closets (with consent naturally).

You can make a list and get most of these items scheduled for the entire year in just a few hours.  Unfortunately, a good number of us will look up at our calendars and realize it's already February long before we get our updates rolling.  Why don't you take a few minutes now to get it done?

Dealing With Santa

This time of year is filled with joy and anticipation of visits from Santa and his reindeer.  In North America we cling to the methodology of Santa Claus with an iron fist.  He's in commercials, he's on soda pop cans, he's at the mall, and tune in to ABC Family or just about any of the dozen's of children networks found on television and you'll see dozens of specials with Santa.  Santa is involved in saving puppies, stopping Jack Frost, and even having a day off.  He's everywhere!  Children usually from the age of about two or three until anywhere between eight and ten cling to the idea that Santa is coming.  It seems like most children around eight to ten begin to figure out that Santa can't go around the world in one night, and that it's odd how much Santa's handwriting looks like mom and dads.  It's that time when families usually sit down together and talk about the legend of Santa Claus and in our case how Santa's spirit of giving in honor of Jesus' birth has been passed from parent to parent.  It can be a sad time, or a joyful time when parents can no longer spend Christmas Eve late planting presents around the tree.  But what about the person who has Intellectual Disabilities?  The person with ID is often regulated by psychologist to an age range of 0-6 years of age for the rest of their lives.  Many of them never stop believing or arrive at the questions their peers may come to.  How do we as professionals deal with Santa Claus?

It's not an easy for professionals.  We are constantly reminded, often by surveyors and others, that we should ensure activities and events are "age appropriate."  It is not really "age appropriate" for Santa to visit a group home of say six forty-something year old men.  But, if you've even been to a Christmas party with people who have diagnosis of ID, then you've seen them respond to the arrival of Santa.  It is like the magic of childhood never leaves.  They scream, get excited, tell him what they want for Christmas and often receive presents already arranged by staff.  To be blunt, it can be a crazy time and fun time!

As professionals, we have to make decisions everyday.  Those of us who work in the ICF programs with the IDTeam to help the person we're serving make the best decisions for his or her life know how tough decisions can be.  We help people decide how much money to spend, when to get a job, if they can take college classes, how long they will be in high school, what medications they will take, what goals they will train on, and so on.  We spend a great amount of time in the ICF setting deciding people's lives all while striving to encourage their independence.  So ultimately with Santa we have a decision to make.  We can tell the person we serve that there is no Santa.  We can tell them the stories of Santa and how he was a real person.  We can tell them that the people who show up to parties are simply carrying on the spirit of Santa.  We can if the IDTeam feels that is important, but in the big scheme of things how important is truth about Santa to the well being of the person who has Intellectual Disabilities?

Maybe it's okay to sit back for one little party each year and let the person believe.  Maybe we should look to that psychological assessment and hold the psychologist to their assessments - if they say 0-6 years of age, then that's the age someone would believe in Santa.  Why not let it be?  We are usually talking about one party a year where the person gets excited, believes that Santa has arrived for the party, and wants to get a present from Santa or even talk to him!  Out of 365 days a year, will a couple of days of Santa really throw the person with an ID diagnosis into a tailspin?  It's not likely to happen.   So, unless there is some sound reason, based on the individual's needs, it's okay to let the party roll, let Santa visit, let everyone have fun and believe.  It's not going to hurt anyone.....and to tell the truth, I've been to a few of those parties where I'm pretty sure the beard was real and it makes me wonder during those moments too!

Link

Dealing with Serious Threats at the ICF/IID Level

Inland Regional Center from
http://www.nbcnews.com/

For those of us working in the ICF/IID field, the unthinkable happened yesterday in California when a shooting took place at a facility for people with developmental disabilities.  The facility serves several thousand people and has an employee list of over five hundred.  This type of shooting could have just as easily have happened in Texas at a state supported living center, a local LAR facility in just about any county, a state run small facility, an HCS setting, or even a private ICF/IID home.  

The shooting in California at a state run facility has brought the very real threat of a potential attack here in Texas home (News Report).  This was not a shooting in a mall, movie theater, or some other large public event where a shooter decided to harm others.  This shooting took place in a facility where people work with people who have developmental disabilities.  It took place with people who could have been our co-workers.  I encourage all facilities to consider putting policies and procedures in place to deal with a threat within the facility immediately or to review your current policy and procedures for these types of events.  This threat could come in the form of a telephone call, digital threat, employee, family member, or an unknown person.  We need to be prepared.  

I am pasting a potential policy and procedure here.  If you wish to have a Word format copy, please email me at (My QIDP)  I will be happy to share this policy with any facility or organization.  If you have specific questions about the policy, do not hesitate to ask me.  If you would like for me to provide training for dealing with a potential event (threat) at your facility, we can arrange that for a small fee to cover travel and expense.  This is too important to minimize.  The shooting in California brings this close to home.  We have very comprehensive disaster plans in most ICF/IID settings in Texas, but I seriously doubt everyone's plan addresses the kind of events we saw unfold yesterday.  

Start: --------------------------------------------------------------------------------------------------------

Policy and Procedure

Date:

Armed Threat, Terrorist Threat or Violence Policy and Procedure

Policy:

It is the policy of the facility to take all precautions possible to ensure the safety and well-being of residents (clients), staff, and visitors during any potential armed threat, terrorist threat or violent threat made toward the facility, a specific individual(s), or on the property owned by the facility at all times.

Procedure:

Telephone or Electronic Threat

1.     In the event of a telephone, text, fax, electronic, or digital threat made against the facility, a specific individual(s) or toward the property owned by the facility, the facility will take immediate action and notify 911 services and the Administration.

2.     A threat against a building or property will be reason for immediate evacuation from the building or property unless otherwise directed by city, county, state or federal officials designated to respond to the threat.

3.     A threat against a specific individual(s) will result in immediate protective action as follows:

a.     Notification of local law enforcement

b.     Follow directions of local law enforcement

c.      Secure or lock down the building or property

Armed Threat / Terrorist Threat or Violence

1.     If there is an armed threat, terrorist threat, or violence event at the facility or on the property of the facility, the facility will take immediate action in response:

a.     If possible, lock the facility or property to slow or stop the event from occurring or proceeding.

b.     If the event has occurred within the property, secure residents (clients) and visitors away from the event as quickly as possible including the possibility of evacuation or lock down.

c.      Immediately notify 911 – follow directions

d.     Leave the 911 line open to allow officials to possibly monitor events as they unfold

e.     Report all known information, including descriptions, number of individuals involved, injured, locations within the facility, etc.

f.      Move residents (clients), visitors, and staff away from any known threat area as orderly and as quickly as possible if move can be accomplished safely.

g.     Care for any injured as quickly as possible

2.     If the event leads to a hostage situation follow these procedures:

a.     Remain as calm as possible

b.     Listen closely to any directions from those holding hostages

c.      Follow directions if provided

d.     In the event of a rescue, be prepared to cooperate with rescuers immediately.

Standing Rules

1.     For any potential event of an armed threat, terrorist attack, or violence, there are certain measures the facility will have in place:

a.     Evacuations routes will be clearly posted.

b.     Security and safety of all residents (clients), visitors and staff will be priority.

c.      Facility address and phone number should be placed clearly next to each phone within the facility.

d.     During non-business hours, and at all times for ICF/IID homes, the facility should be locked and secured with the obvious exception of such times as residents (clients) are using outside facilities.

e.     All staff will be trained on this policy.

f.      The facility will have one “Armed Threat / Terrorist Threat or Violence Threat” drill each calendar year.

g.     The administration will review and revise procedures pending results of the annual drill.

h.     Any part of this policy and procedure may be modified, changed or deleted at any time during the year by administration and at anytime during an actual event by city, county, state, or federal officials designated to respond with an event.

i.       Once security has been maintained, the Administrator or Designee will notify DADS of the incident and follow recommendations or outlines as directed.

j.       The facility will designate one person to act as “Spokesperson” for the facility.  The spokesperson will respond to any news or media questions or inquiries on a local, state, or national level. 

k.     Staff other than the spokesperson may only respond to any news and media questions with “No comment” unless otherwise given permission by the spokesperson or the facility Administrator or designee.

Missing Resident or Out Walking

ICF/IID programs in Texas have dealt with the question of when to report a missing resident for years.  I was recently visiting with a program when a staff person reported, "This person is missing!  We think they ran off."  A management staff sitting nearby quickly pointed out, "No, they are not missing, they are out for a walk!"  While it was a serious moment, the comic relief provided is a view that many facilities have to deal with daily.  We live in a world where residents are encouraged to exercise their rights and one of the many rights they often exercise is the right to move freely on and off the facility site.  The question the facility has to face, is when does that right become a reportable incident. 

The Texas Administrative code offers some insight into this issue (Texas Code).  In this code we read that "a resident whose location has been unknown by the facility for more than eight hours or less than eight hours if there are circumstances that place the resident's health or safety at risk."  This standard would appear to be clear, but sadly it is not.  It leaves itself wide open for interpretation.   The first half is fairly clear - if the resident has been missing from the facility for more than eight hours.  That's easy enough in that you check the last known time the resident was in the facility against the current time.  If it is less than eight hours, the resident is not missing - they are simply out for a walk.  If it is over eight hours, then they are considered missing. 

The second part of the code presents issues that are open for interpretation.  In the second part, we suddenly find it stating "or less than eight hours if there are circumstances that place the resident's health or safety at risk."  Who decides what those circumstances are?  If the resident has a guardian, does the guardian determine them?  If there is no guardian, does the IDTeam determine them?  Does the QIDP determine them?  Does the nurse determine if risk are present?  Or, does the surveyor who arrives and reviews the incident determine that the individual was at risk?  The fact is, the level of risk for the individual is usually not determined by anyone until the incident occurs.  

The standard routine for most facilities is rounds are made and the staff find that a resident is missing.  This may be the first time the resident has ever gone missing.  The staff calls administration, or the QIDP.  They discuss it.  The administration and others may go out and start looking around the area.  They go to local stores, parks, schools, and even check with neighbors.  In the end, the resident is usually found safe or even brought back to the facility by local law enforcement.  Most facilities let out a sigh of relief because the person was found within eight hours and they never look further at the standard.  Later, a surveyor shows up and reads about the incident in an exam report, or even a QIDP note.  The surveyor goes and looks further and finds no assessments for the resident's ability to move around the community.  The surveyor then goes and talks to the resident and determines that the resident was in an unsafe situation and that the facility failed to call in the allegation.  Boom!  There's your first tag on your 2567!  

So how can a facility prepare for the day a resident decides to take a walk?  There are actually several things a facility can do:

1.  If a guardian is involved, have them indicate what they desire for the resident.  In other words does the guardian know any reason the person would be unsafe going to a store alone should they leave the facility. 

2.  Develop a community based assessment- does the resident know about looking for traffic before crossing a street, does the resident know about red lights and crosswalks, what type of community do you live in - rural with few traffic issues, or next to an interstate with major traffic?  

3.  Have the IDTeam review and if necessary develop a plan to deal with "walks" or "elopements".

4.  Have facility policies specifically stating what the facilities view is on residents leaving.  

If the facility is completely honest, there will likely be a list of residents who can go out and easily come back on their own with no concerns.  There will also be a list of residents who should not be out on their own without supervision.  There may even be a list of residents that can do well in known areas, but not in unknown areas.  If you have a list, assessments, and IDTeam's reviews  and find that you face a surveyor who decides an individual can not be out safely from the facility, then you can present that information to the surveyor and be prepared if necessary to do an IDR for any tags cited. 

I recently had a resident in a facility who would walk to the store at the end of the block.  He would do this daily, especially when he had spending money.  He would go into the living room, announce to the staff that he was going to the store, and he would walk to the store.  Within about twenty to thirty minutes he would come back.  Assessments indicated he had the ability to safely move through the neighborhood, the IDTeam had reviewed it, and he had a service goal indicating that he could walk to the store.  The goal also indicated that he was usually only gone for about thirty to forty-five minutes.  During the time this individual lived in the home, survey arrived.  The surveyor questioned me about the individual and I provided the information.  She reviewed it and moved on to the next concern.  We received no deficient practice; however, I feel strongly that if we had not had the assessment and the IDTeam review, there would have been greater concerns expressed and to be honest there would be good reason for those concerns.